Inspection·February 14, 2025

F 0755 * Level of Harm - Immediate jeopardy to resident health or safety Resident # 1 has impaired cognition and is at risk for further decline and injury AEB. Goal: Resident # 1 needs will be met, and dignity maintained over the next 90 days. Interventions: All time for task and responses; explain all procedures using terms/gestures the resident can understand; and involve in care to maintain or increase level of independence. Residents Affected - Few * Resident # 1 was at risk for Stroke. Goal: Resident # 1 will remain free of Stroke like symptoms. Interventions: if symptomatic, perform Cincinnati Prehospital Stroke evaluation. * Resident # 1 has an adverse reaction to medication. Goal: Resident will be monitored for symptoms related to the adverse reaction due to polypharmacy. Interventions: add medication to tolerance list until allergy can be confirmed; administer allergy medication per facility protocol or standing order; evaluate breathing; and evaluate circulation. Record review of Resident #1's physician's orders for February 2025 revealed the following active medication orders: * Aldactone Oral Tablet 25 MG (Spironolactone). Give 1 tablet by mouth one time a day related to Edema. Active: 11/2/2024 * Furosemide Oral Tablet 40 MG. Give 1 tablet by mouth one time a day for Edema. Active: 10/1/2024 * Melatonin Oral Tablet 3 MG. Give 1 tablet by mouth at bedtime related to Insomnia. Active 10/1/2024 * Midodrine HCL Oral Tablet 10 MG. Give 10 mg by mouth three times a day for hypotension hold if systolic blood pressure is over 120. Active date: 2/10/2025 * Polyethylene Glycol 3350 Powder. Give 1 scoop by mouth one time a day related to Constipation. Active 10/2/2024 * (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Trazadone HCL Tablet 50 MG. Give 1 tablet by mouth at bedtime related to Generalized, Anxiety Disorder. Active 10/2/2024 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's physician's orders for February 2025 revealed the following discontinued medication orders: Residents Affected - Few * Midodrine HCL Oral Tablet 10 MG. Give 10 tablet by mouth three times a day for hypotension hold if systolic blood pressure is over 120. Start date 1/2/2025 and Discontinued date 2/9/2025. * Black box warning for Midodrine - Appropriate use Because midodrine can cause marked elevation of supine blood pressure, it should be used in patients whose lives are considerably impaired despite standard clinical care. The indication for use of midodrine in the treatment of symptomatic orthostatic hypotension is based primarily on a change in a surrogate marker of effectiveness, an increase in systolic blood pressure measured 1 minute after standing, a surrogate marker considered likely to correspond to a clinical benefit. * Dose Warning: This order is outside of the recommended dose or frequency Midodrine HCl Oral Tablet 10 MG. Give 10 tablet by mouth three times a day for hypotension hold if SBP greater than 120. The dosing regimen of 10 tablets 3 times per day exceeds the usual dosing regimen of 0.25 tablet daily to 1.75 tablets 3 times per day. The single dose of 10 tablets exceeds the maximum single dose of 1.75 tablets. The usual dosing regimen is 0.25 tablet daily to 1.75 tablets 3 times per day. Record review of order details revealed, dated 1/2/2025, revealed Midodrine HCL Oral Tablet. Give 10 tablet by mouth three times a day for hypotension; hold if systolic blood pressure is above 120. Record review of nurses note, dated 2/9/2025, revealed MA A administered 100 mg of Midodrine instead of 10 mg to Resident # 1 and prior to MA A administering this medication Resident # 1 blood pressure was 110/53 at 9:25 pm. Resident # 1 blood pressure was 189/96 at 10:10 pm. Record review of medication administration record revealed on 2/9/2025 at 9:00 pm there was no documentation for the administering of Midodrine. Record review of medical records from a local hospital revealed Resident # 1 was admitted on [DATE] with a diagnosis of drug overdose, accidental or unintentional with blood pressure 191/99. The admitting physician documented unsure why Resident # 1 was on Midodrine given documented history of hypertension, reportedly patient received 100 mg of Midodrine instead of usual 10 mg. In an interview on 2/11/2025 at 10:30 am, Medical Director stated he were not the attending physician for Resident # 1. He stated that he was aware Resident # 1 was administered medication in error by a MA. He stated that Resident # 1 was administered Midodrine in error. He stated that a resident was given to much Midodrine and the adverse consequences could result in altered mental status, respiratory distress, neurological changes, nausea, and vomiting. He stated that he expected the Nurses and MA's to administer medication as ordered, review medication, and give medication correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In a telephone interview on 2/11/2025 at 10:45 am, EMS staff stated that Resident # 1 was administered an overdose of Midodrine. She stated that when EMS arrived at the nursing facility Resident # 1's blood pressure was 189/96. She stated she was told that Resident # 1 was given 100 mg of Midodrine instead of the 10 mg. She stated that she spoke with MA A who stated she gave Resident # 1 10 tablets of Midodrine. She stated that MA A told her this medication was given to Resident # 1 at 9:25 pm. She stated that the nursing facility did not contact EMS until 10:10 pm. She stated that Resident # 1 was transported to a local hospital. She stated that when Resident # 1 arrived at the local hospital Resident # 1's blood pressure was 191/99. In an interview on 2/11/2025 at 3:02 p.m., Nurse E stated that on 2/9/2025 MA A showed her the orders for Resident # 1 and the written order revealed to administer 10 tablets. Nurse E stated that MA A told her that she had given Resident # 1 10 Midodrine tablets. She stated that she immediately informed Nurse B as she was the supervisor. She stated if a resident was administered too much Midodrine the adverse consequences can be stroke, myocardial infarction and the blood pressure will go up. In an interview on 2/11/2025 at 3:09 pm Nurse B she stated that on 2/9/2025 at approximately 9:00 p.m. MA A informed her that she gave Resident # 1 medication incorrectly. She stated that MA A administered 10 Midodrine tablets to Resident # 1. She stated that she reviewed Resident # 1's orders in the PCC and the written orders reflected: 10 Midodrine (10 mg) tablets 3 times a day; hold if systolic blood pressure is over 120. She stated that she checked Resident # 1's blood pressure and it was 125/could not remember the diastolic number. She stated that 911 was contacted immediately. She stated that when EMS arrived Resident # 1's blood pressure was 189/she stated she could not remember the diastolic number. She stated that the order on the blister pack was Midodrine 10 mg- give 1 tablet three times a day hold if systolic blood pressure is higher than 120. She stated if a resident was administered too much Midodrine the adverse consequences can be increased blood pressure and this could result in a stroke. In an interview on 2/11/2025 at 3:40 p.m. Nurse A stated that MA A asked her to look at the medication. She stated that MA A told her that she gave Resident # 1 10 Midodrine tablets. She stated at the time of this incident Resident # 1's blood pressure was 125/could not remember diastolic number. She stated that EMS arrived 20 minutes later and Resident # 1's blood pressure was 189/96 and Resident # 1 was transported to the local hospital. She stated if a resident is administered to much Midodrine the adverse consequences are hypertension, feeling dizzy, headache and heart failure. In an interview on 2/11/2025 at 3:59 p.m., ADON A she stated that she was the nurse who took the orders and entered the orders in the system. She stated that the NP ordered Midodrine 10 mg three times a day to be given if they systolic is below 120. She stated that she did not realize that she entered 10 tablets instead of 10 mg. She stated if a resident is administered to much Midodrine the adverse consequences are high blood pressure could result in a stroke. In an interview on 2/11/2025 at 4:19 pm, Pharmacy Consultant, stated that she did not recall reviewing Resident # 1's medication regiment. She stated that she reviews the medication regiment and she makes sure they have the correct diagnosis and dosages. She stated that she reviews PCC and the blister packs. She stated that she reviews the medication remotely and she must have seen 10 mg instead of 10 tablets. She stated if a resident is administered to much Midodrine the adverse consequences are hypertension, headaches, and dizziness. In an interview on 2/11/2025 at 4:35 p.m. MA A she stated that Resident # 1 orders read administer 10 tablets of Midodrine. She stated that she administered 10 tablets of Midodrine to Resident #1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She stated that she took Resident # 1's blood pressure and it was 110/50 something. She stated that she looked at the MAR and per the MAR she was to hold the Midodrine as Resident # 1's blood pressure was not over 120. She stated that she was told to follow the directives as listed on the MAR and she popped 10 tablets from the blister pack and she administered 10 tablets to Resident # 1. She stated that she thought orders on the MAR was wrong, but she had administered the medication to Resident # 1. She stated if a resident is administered to much Midodrine the adverse consequences are high blood pressure, stroke or heart attack. In an interview /observation on 2/11/2025 at 5:15 p.m. Resident # 1 stated that she was well. Resident # 1 was fixing the linen on her bed. Resident # 1 did not have any knowledge regarding her medication. She stated that she did not have any concerns. In an interview on 2/12/2025 at 11:05 a.m., NP revealed her to deny making a verbal order for 10 tablets of Midodrine three times a day. She stated that she ordered 10 mg of Midodrine three times a day hold if the systolic blood pressure is over 120. She stated that giving Resident # 1 10 Midodrine tablets could have caused Resident # 1 to have high blood pressure and a stroke. She stated that she was told that Resident #1 was given 10 Midodrine tablets. She stated that she ordered for Resident # 1 to be sent to the hospital immediately. In an interview on 2/12/2025 at 12:48 p.m., MA B stated that she was trained to follow the MAR. She stated that if the MAR and blister are not matching, she would tell the nurse. She stated that Midodrine was given to residents who have hypotension. She stated that before Midodrine was administered the MA or nurse must follow the parameters. She stated before administering Midodrine the resident's blood pressure must be checked, and the blood pressure must be within the parameter on the resident's order. She stated that she has administered Midodrine to Resident # 1 and she stated she did not notice the order on the MAR said 10 tablets. She stated that was an error. She stated that as a MA she knows that it is not normal to give a resident 10 tablets out the same blister pack. She stated that normally residents will receive one or two pills out the same blister pack. In an interview on 2/12/2025 at 1:04 p.m., Nurse C stated Midodrine was used to elevate the blood pressure. She stated that residents normally get 1 tablet and 5-10 mg. She stated that if a resident is administered to much Midodrine the resident's blood pressure is rise quickly and this can lead to a stroke. She stated that vital signs will change immediately. She stated if this order was put into the MAR incorrectly the nurse will receive an error message. She stated the management team was responsible for monitoring the orders and making certain the MAR and the blister pack matches. In an interview on 2/12/2025 at 1:18 pm, Nurse D stated she has worked with Resident # 1. She stated that Resident # 1 took Midodrine for hypotension. She stated that Resident # 1 took 10 mg of Midodrine one tablet, three times a day. She stated that the parameters were hold if the systolic blood pressure is more than 120. She stated that the protocol for administering medication is ensure it was the right person, right medication, and right dosage. She stated that if a resident is given to much Midodrine the resident's blood pressure will be high and this can lead to a stroke and/or heart attack. In an interview on 2/12/2025 at 1:42 p.m., Nurse J once she received a verbal order from the NP or physician she must verify the order by repeating the order to the doctor. She stated that when she put the order in PCC she must verify and make certain the order was correct. She stated that Midodrine is used for residents that have low blood pressure and it has parameters. She stated that the normal dosage for is 5 to 10 mg it depends on the order. She stated that the blood pressure must be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few checked prior to administering the Midodrine. She stated that the adverse consequences are headaches, nose bleeds, dizziness, and a stroke. In an interview on 2/12/2025 at 1:57 p.m., the DON, revealed that she was made aware of the Midodrine situation on 2/10/2025. She stated that the nurse called and texted her on 2/9/2025, however, she did not hear her phone ring as it was late. She stated that the normal range for Midodrine is 5mg-20 mg to be given if the systolic is with 110-120 parameters. She stated that she was told that Resident # 1 was administered 10 tablets of Midodrine. She stated that this could have cause Resident # 1's blood pressure to elevate and possibly a stroke. The DON stated that she should get a report of the irregularities identified on the MRR. She stated that the if the medication is different between the MAR and the blister pack staff should clarify before giving the medication to the resident. She stated that the MA's should inform the nurse if there any medication discrepancies. The nurse should clarify any medication discrepancies with the resident's physician and/or nurse practitioner. In an interview on 2/12/2025 at 2:18 p.m., the Administrator, stated that he was notified on 2/9/2025 that Resident # 1 was sent out to the hospital. He stated that on 2/10/2025 he was made aware that it was a medication error and Resident # 1 was given more medication than the card stated. He stated Resident #1 was sent out to the hospital immediately. He stated that the medication was not self-reported because at the time there was no indication of an allegation of abuse and no indication of neglect and there were no adverse situation that occurred. The Administrator stated that the following was taken: every resident was audited on Midodrine for accuracy, education transcript for nurses, the rights of administration for the nurses and MA's, MA A and ADON A received one on one education and disciplinary action, an ADHOC QAPI meeting, and abuse and neglect in service. The Administrator stated that he expected that if there was a medication error, staff assess patient, document, notify the physician or NP, notify the resident's family, and notify the DON. In a follow up interview with ADON A on 2/12/2025 at 3:24 p.m. she stated that on 2/10/2025 she was in serviced on the 10 rights of Drug Administration which include right time, right frequency, right dosage and right medication. She stated she was also in serviced on transcribing to include repeating the orders back to the NP and/or physician and double-checking orders when putting the orders in PCC. She stated she also had skills check training which consisted of passing medication to include checking the MAR and blister pack and making certain she gave the right medication to the right patient. In a follow up interview with MA A on 2/12/2024 at 3:33 p.m. MA A stated that on 2/10/2025 she was in serviced on the 10 Rights of Drug Administration to include right time, right resident, right drug, right dosage and resident history. MA A stated that she was in serviced on Midodrine and she stated Midodrine is a medication that raised blood pressure and has parameters. In an interview on 2/12/2025 at 3:42 p.m., MA C stated that she has administered Midodrine to Resident # 1. She stated Midodrine was given to residents who have hypotension. She stated if a resident is administered to much Midodrine the adverse consequences for the resident is shock and high blood pressure. She stated that Resident # 1 has orders for Midodrine 10 mg (1 tablet) three times a day and the parameters are to hold the medication if Resident # 1's systolic blood pressure is higher than 120. She stated that when giving a resident medication she reviews the MAR and blister pack. MA C stated she did not notice Resident # 1's orders on the MAR read 10 tablets. MA C stated that on 2/10/2025 she was in serviced on the 10 Rights of Drug Administration to include right drug, right patient, right dosage, evaluation, and right to refuse. She stated that on 2/10/2025 she was in serviced on the medication Midodrine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An Immediate Jeopardy (IJ) was identified on 2/13/2025 at 12:35 pm, due to the above failures. The Administrator and DON were notified. The Administrator and DON was provided the IJ template at 12:37 pm. The following Plan of Removal was submitted by the facility and was accepted on 2/13/2025 at 6:37 pm: Plan of Removal

F755 Resident was administered 100mg of Midodrine instead of the verbally ordered amount of 10mg. Resident assessed by LVN and sent to ER for evaluation. (returned 2/11/2025) Family called MD/NP notified. Audit all Midodrine orders by DON 2/10/2025 Resident #1 medication clarified/fixed 2/10/2025 (ultimately discontinued upon hospital return) Notify Medical Director 2/10/2025 11:03am brief QAPI discussion to establish plan (this) New orders will be reviewed by DON/designee daily to ensure accurately transcribed and that the computerized order matches the medication card. Results of these audits will be discussed in morning meeting and any discrepancies will be rectified immediately. LVN disciplinary action and 1:1 education 2/10/2025 related to transcription and medication administration to ensure the computerized order matches the medication card. MA disciplinary action and 1:1 education 2/10/2025 related to medication administration to ensure the computerized order matches the medication card. MA removed from MA role as of 2/10/2025 until further education and training occurs and she successfully completes 3 competency checks by DON. Facility MAs and nurses re-educated on medication administration started 2/10/2025 by the DON. Education was completed on 2/11/2025 and staff not allowed to work without training completion. The education consisted of right person, right time, right dosage, right route, right drug. Also included matching computerized order to medication card. Nurses and MAs were provided education and post-test for Midodrine administration specifically by the DON on 2/10/2025 and no one can return to work unless education has been completed. Nurses re-educated on transcription of orders/meds started 2/10/2025 by the DON. Education was completed on 2/11/2025 and staff not allowed to work without training completion. This education consisted of rights as well as repeating back to prescriber for accuracy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Notified Pharmacy Consultant by DON 2/11/2025 and will review all active residents' entire medication regimen monthly and provide verbal and written reports for verification. Next visit scheduled for week of 2/17/2025. Abuse, Neglect & Exploitation re-education started 2/11/2025 by the DON for all active staff members to include types, coordinator, and notification. This was completed on 2/11/2025 and staff may not return to work until the education is completed. Full Ad hoc QAPI 2/11/2025 with Medical Director present DON audit all new orders from 2/1-2/11/2025 on 2/11/2025 with no inaccuracies found. DON/designee to complete 100% audit of all medications for all current residents completed 2/13/2025 with no discrepancies identified. Policies Reviewed with no changes required: Abuse, Neglect and Exploitation, Medication Administration, Medication Orders, Medication Regimen Review. Monitoring for implementation of the POR was conducted on 2/14/2025: In a telephone interview on 2/14/2025 at 10:30 am MA D stated that she was in serviced on 2/10/2025. She stated that she was in serviced on 10 Rights of Drug Administration to include right drug, right patient, and right dosage. She stated that was in serviced on passing medication to include making certain the MAR and the blister packs match. She stated if the MAR and the blister pack does not match, she must report it to the nurse. She stated that she was in serviced on Midodrine to include what the medication is for and the parameters. In an interview on 2/14/2025 at 2:42 pm Nurse F stated she received an in -service on 2/10/2025 regarding 10 Rights of Drug Administration, Midodrine, Medication Administration and Medication Transcribe. She stated that 10 rights of drug administration include right medication, right patient, right time, right dosage, and right documentation. She stated that when taking orders from NP or physician she must repeat the order back to the NP/physician. She stated that if there any discrepancies with the residents orders she must contact the NP or physician. In an interview on 2/14/2025 at 3:15 pm with Nurse G he stated he was in serviced on 2/10/2025. He stated he was in serviced on Medication transcription, 10 rights of drug administration, medication administration and Midodrine. He stated that Midodrine is a medication used mainly with residents who have hypotension, and this medication is used to raise blood pressure. He stated that the normal dosage 1 tablet and 5-10 mg. He stated that this medication is administered based on the parameters. He stated the rights of drug administration include right medication, right patient, right medication, right dosage, right [NAME], right time, right documentation, history, assessment and evaluation. In an interview on 2/14/2025 at 3:27 pm with ADON B she stated she in serviced the Nurses and MA's on 2/10/2025. She stated that the in-services were 10 Rights of Drug Administration and Midodrine. She stated that staff were in serviced to follow upon each medication. If there is a discrepancy between the blister pack and the MAR staff should notify the nurse manager immediately prior to administering the medication. She stated that she in serviced the Nurses and CMAs on the medication Midodrine. Staff was in-serviced that Midodrine is used to treat low pressure and each Midodrine should have parameters. She stated she was in serviced on medication transcription and administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety In a telephone interview on 2/14/2025 at 3:45 p.m., Nurse A she stated she was in serviced on 2/12/2025. She stated that she was in serviced on the medication Midodrine, 10 Rights of Drug Administrations, and Medication Administration. She stated that the in services covered transcribing to include repeating the orders back to the NP or physician. She stated that if there is a medication the on-call physician should be contacted immediately. She stated that she was in services on the 10 rights of medication to include right patient, right medication, right dose, right route, right documentation, and right time. Residents Affected - Few In an interview on 2/14/2025 at 3:50 pm, Nurse H stated in serviced on 2/10/2025. She stated that she was in serviced on 10 Rights of Drug Administration, Midodrine, Medication Administration and Transcribe. Nurse H stated that the resident has the right to dignity, the right to refuse, the right to grievances. She stated that Midodrine is used to treat hypotension and when a resident is taking Midodrine there are parameters specific to that resident as ordered by the NP or physician. Nurse H stated that the adverse consequences of the medication Midodrine are high blood pressure, dizziness which could lead to elevated blood pressure and stroke. She stated that the 10 rights of medication-right patient, right medication, right dose, right route, right time and right documentation. She stated that when taking orders from the NP or physician the order must be read back to the NP or physician for accuracy. In an interview on 2/14/2025 at 4:10 pm, Nurse I stated she was in serviced on 2/10/2025. She stated that she was in serviced on Midodrine. She stated that Midodrine is used for low blood pressure. She stated that if a resident is given to much resident the adverse consequences could be heart failure. She stated that she in serviced on medication transcribing to include check order and make certain it the orders has the correct date, time, route and repeat the orders back to the physician. She stated she was in serviced on the 10 Right of Drug Administration to include right medication, right patient, right route, right time, and right to refuse. She stated that if a medication is given error the supervisor and NP need to be contacted immediately. In an interview on 2/14/2025 at 4:30 p.m., Nurse B stated she was in serviced on 2/10/2025. She stated that she was in serviced on Midodrine. She stated the order on the MAR must match the blister pack. She stated that Midodrine has parameters, and this must be notated on the MAR and the blister pack. She stated that when verbally receiving orders from the NP or physician she must repeat the order back for accuracy. She stated that was in serviced on Midodrine. She stated that Midodrine is given to residents who have low blood pressure. She stated that this medication must be administered according to the NP or physician's order. She stated that was in serviced on the 10 Rights of Drug Administration. Nurse B stated both in services were completed on 2/14/2025. In an interview on 2/14/2025 at 4:45 p.m., Resident # 1 stated she was well and she did not have any concerns. She stated did not know anything about her medication. She stated that staff administers the medication, and she could not remember anything else pertaining to her medication. Record review of the facility's Pharmscript policy dated (8/2020) revealed read in part .The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify communicate, address and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but not limited to:5 d) Assisting in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors and the provisions of and monitoring of the use of medication-related devices, 6a) reviewing the medication regiment of each resident at least monthly or [NAME] frequently under certain conditions, incorporating federally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review findings in the resident's medical record or in a steadily retrievable format if utilizing electronic documentation, 6g) reviewing medication administration records (MARs), treatment administration records (TARs) and physician orders to ensure proper documentation of medications orders and administration of medications to residents. Record review of the facility's Medication Regimen Review Verification (MRR) dated January 2025 revealed on 1/9/2025 the pharmacist consultant reviewed Resident # 1 MRR and documented Medication Regimen Review has been performed and any inappropriate findings were communicated to the Physician and Director of Nursing through the utilization of the Pharmaceutical Consultant Report. The current prescription therapy is considered appropriate at this time and any indicators concerning the Interpretive Guidelines will be addressed when clinical conditions warrant such attention. Record review of the facility's Nursing Policies and Procedures dated (revised 6/2019) revealed read in part The facility's nursing and pharmacy services will assess, monitor and evaluate the effectiveness of the therapeutic medication regimen including all drugs ( prescription and non-prescription) in order to enhance the resident's quality of life; 3) the authorized licensed or certified/permitted medication aide or by state regulatory or guidelines staff members follow the MAR prepared for the patient/resident/by identifying: a)right resident, b)right drug, c)right dose, d)right time, e) right route, f)right charting, g)right results and h) right reason, 4) The authorized licensed or certified /permitted medication aide or by state regulatory guidelines staff member identifies, that the following information, but not limited to, id documented on the MAR: a)correct physician's order, b)medication and label are correct, and c) label and physician's order are correct; 5) The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member reads the label on the medication three (3) times: a)before removing the medication from the drawer, b) before pouring the medication and c)after pouring the medication;6) The authorized licensed or certified/permitted [NAME][TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 10 of 10